Achalasia and Cricopharyngeal Sphincter Dysfunction in a Patient With Myasthenia Gravis: A Case Report.

This case report describes an 82-year-old female patient with myasthenia gravis (MG) who presented with worsening dysphagia. The patient was found to have cricopharyngeal sphincter and esophageal achalasia, and a percutaneous endoscopic gastrostomy (PEG) tube was placed due to severe pharyngeal dysphagia and cricopharyngeal dysfunction. The patient had class IVb myasthenia gravis and was treated with intravenous immunoglobulin (IVIG), prednisone, and pyridostigmine. The report discusses the link between myasthenia gravis and dysphagia, which is seen in 20% of patients. The report also explores the relationship between myasthenia gravis and achalasia, which is a rare disorder characterized by the failure of relaxation of the sphincter muscles. While myasthenia gravis leads to muscle weakness and should not cause achalasia, there have been a few case reports describing a link between the two disorders. Cricopharyngeal dysfunction, which is a common disorder causing dysphagia in the elderly, was also noted in the patient. The report highlights that cricopharyngeal dysfunction may be primary or secondary, with the latter often being associated with inflammatory myopathies such as polymyositis or mixed connective tissue disorders. The patient did not have a workup for other autoimmune diseases that could have been the cause of achalasia.

Severe COVID-19-Induced Hemophagocytic Lymphohistiocytosis.

We reported a case of secondary hemophagocytic lymphohistiocytosis (HLH), a rare and life-threatening condition, which was suspected to have been triggered by a severe case of coronavirus disease 2019 (COVID-19). A 50-year-old man with a past medical history of ulcerative colitis with recent pancolitis status post colectomy and ileostomy two weeks before presentation presented to the emergency department with one week of subjective fevers, weakness, watery diarrhea, and decreased oral intake. A CT scan showed fluid in the rectum and post-surgical changes from his recent colectomy along with diffuse reticulonodular opacities of the lungs. His COVID-19 reverse transcriptase-polymerase chain reaction (RT-PCR) test was positive. Over the subsequent days, the patient's condition worsened as he developed worsening acute hypoxic respiratory failure with diffuse lymphadenopathy, splenomegaly, worsening cytopenias, and increased ferritin of >100,000 ng/ml on hospital day six. Hematology oncology was consulted and he was started on empiric steroid therapy followed by etoposide. However, his condition continued to worsen, and eventually, the patient passed away on hospital day eight.

Indwelling Pleural Catheter (IPC) for the Management of Hepatic Hydrothorax: The Known and the Unknown.

BACKGROUND: Hepatic hydrothorax (HH) is described as pleural effusion secondary to liver cirrhosis after ruling out other etiologies. We aim to assess the efficacy of an indwelling pleural catheter (IPC) placement in refractory HH in this systematic review and meta-analysis. METHODS: A comprehensive search of literature was performed from inception to December 2020. The authors reviewed, selected, and abstracted the data from eligible studies into Covidence, a systematic review software. Cochrane criteria was used to rate each study for the risk of bias. The data abstracted were described using a random-effects model. Heterogeneity was evaluated using the I2 test. RESULTS: Ten studies involving a total of 269 patients were included. The studies were analyzed for the proportion of pleurodesis achieved, the average time to pleurodesis, total complication rate, pleural infection rate, and mortality. A proportion of 47% of the total subjects included achieved spontaneous pleurodesis in an average duration of 104.3 days. The frequency of total complication rate was noted to be 30.36%. The incidence of pleural cavity infection was described to be 12.4% and death resulting from complications of IPC was 3.35%. CONCLUSION: The current management options for the refractory pleural effusion in HH include repeated thoracenteses, transjugular intrahepatic portosystemic shunt, surgical repair of defects in the diaphragm, and liver transplantation. However, the cost, eligibility, and availability can be some of the major concerns with these treatment modalities. With this meta-analysis, we conclude that IPCs can provide an alternative therapeutic option for spontaneous pleurodesis.

A case of hemothorax secondary to intrapleural fibrinolytic therapy: Considerations for use of fibrinolytics in high-risk patients.

Indwelling Pleural Catheters (IPC) are increasingly being used for management of recurrent pleural effusions (RPEs). Use of IPC for management of both malignant and non-malignant recurrent pleural effusions has been associated with complications such as dysfunctional or nonfunctioning IPCs. Alteplase, a tissue plasminogen activator (tPA) is often used to restore flow of non-draining IPC in symptomatic patients. We present a case of a sixty-eight-year old patient with life-threatening pleural hemorrhage following intrapleural catheter instillation of tPA that was managed successfully by thoracotomy. Our case describe the importance of individualizing the fibrinolytic dose, frequency and the indwelling time in high risk patients. We have reviewed the current literature and recommendations for use of fibrinolytic therapy for IPC in high risk patients on anticoagulation.

Delayed anaphylaxis due to gadolinium- A rare clinical scenario.

Acute respiratory distress syndrome is a sudden in onset, diffuse inflammatory form of lung injury which may be associated with a variety of etiologies such as pneumonia, sepsis, aspiration, and severe trauma. Prompt recognition and treatment of acute respiratory distress syndrome is critical to reduce the associated high mortality. Severe lung injury presenting as acute respiratory distress syndrome secondary to gadolinium contrast media (gadobutrol) is rarely reported. We describe an interesting case of a 47-year-old woman who presented to the emergency department with acute respiratory failure after gadolinium administration. She was diagnosed with acute respiratory distress syndrome, was admitted to the intensive care unit due to requiring mechanical ventilation. Her condition improved with epinephrine and steroids and she was successfully extubated and discharged from the hospital in one week.

Late presentation of lung adenocarcinoma in a stable solitary pulmonary nodule: A case presentation and review of the literature.

A 67-year-old patient has been followed by our pulmonary clinic for Chronic obstructive pulmonary disease (COPD) and a stable pulmonary nodule. Solitary pulmonary nodule (SPN) was detected on the lung cancer screening by low dose computed tomography (CT) scan of the chest. It remained stable on repeat CT scan at 6, 12 and 24-months interval. Yearly lung cancer low dose CT scans of the chest showed stability of the SPN for 12 years. A mechanical fall necessitating trauma workup unveiled increase in size of the nodule from 4 mm to 11 mm within one year of the previous screening CT chest. Biopsy and Histopathology confirmed the diagnosis of lung adenocarcinoma. The patient then underwent right upper lobectomy followed by chemoradiation therapy. Current guidelines do not recommend follow up for a solitary pulmonary nodules less than 6 mm nodule if it remains stable for 12-24 months. Our case report of the late presentation of lung adenocarcinoma in a stable solitary pulmonary nodule suggests the need to exercise increased caution in the management of incidental pulmonary nodules.

A Case of Laryngeal Tuberculosis, Endobronchial Tuberculosis and Pulmonary Tuberculosis Coexistent in an Immunocompetent Host.

Historically associated with poor prognosis seen in advanced disease, laryngeal tuberculosis (LTB) now represents only 1% of all cases of tuberculosis (TB). The incidence of LTB has decreased drastically with the introduction of anti-tubercular drugs. LTB can be primary or secondary to pulmonary tuberculosis. LTB can mimic laryngeal cancer. We present a case of primary laryngeal TB with descending tracheobronchial spread in an immunocompetent 71-year-old female who developed progressive dysphonia over several months with unintentional weight loss and non-productive cough. Non-contrast enhanced computed tomography (CT) revealed clustering of subcentimeter stellate nodules in the right upper lung field with an enlarging ground-glass opacity in the right lower lung but did not show structural abnormalities within the neck. Positron emission tomography (PET) showed pathologic fluorodeoxyglucose (FDG) uptake within the larynx and trachea with extension into the left mainstream bronchus as well as the proximal left upper and lower lobe bronchi. Diffuse standardized uptake value (SUV) was greatest in the larynx (20.5). Polymerase chain reaction (PCR) on bronchoscope sputum specimen confirmed Mycobacterium tuberculosis. Findings were consistent with primary laryngeal TB with endobronchial extension. She was started on a four-drug regimen comprising of isoniazid, rifampin, ethambutol, and pyrazinamide with a good response. Her close contacts were treated as well. This case highlights the unusual spread of primary laryngeal TB in an immunocompetent host. Early diagnosis can limit adverse complications and unnecessary exposure to healthcare workers. To our knowledge, this is the first case of primary LTB with proximal spread to the tracheobronchial and pulmonary tuberculosis.

Seizure and COVID-19: Association and review of potential mechanism.

Since the emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in Wuhan, China, this highly transmissible virus has since spread rapidly around the world. Though respiratory complication is the primarily reported manifestation though rare, yet serious neurological complications are being frequently reported in the literature. In selected coronavirus disease-2019 (COVID-19) cases neurologic complications may manifest as seizures. In this paper, we have reviewed current literature on seizures linked with SARS- COV 2 infection including published or pre-print original articles, review articles, and case reports. We have discussed the electroencephalogram (EEG), imaging, and Cerebrospinal fluid (CSF) findings in patients with COVID-19 presenting with seizure. We will be concluding the paper by briefly discussing the three mechanisms by which seizures can develop in patients infected with SARS- COV 2 - (a) Direct Mechanism (b) Indirect Mechanism and (c) Exacerbation of Seizure in Patients with Epilepsy (PWE). Our aim is to update the physicians working with COVID-19 patients about this potential complication and hope that understanding of these proposed mechanisms can provide an opportunity for the physicians for early diagnosis or even better, help prevent this complication.

Correction: Lithium-induced Cardiotoxicity: A Rare Clinical Entity.

[This corrects the article DOI: 10.7759/cureus.7286.].

Mediastinal recurrence after curative resection of colon cancer: A case report and review of literature.

Colorectal carcinoma is one of the most common and significant causes of cancer-related death. Metastasis to mediastinal lymph nodes and/or pleura without liver or lung involvement is an atypical pattern of colon cancer metastasis. A 70-year-old male underwent curative right side hemicolectomy and omentectomy for ascending colon cancer followed by adjuvant chemotherapy. Around nine months after surgery, the patient was noted to have bilateral large pleural effusions on the restaging computed tomography scan of the chest/abdomen/pelvis. No intraabdominal or intrathoracic mass/metastasis was seen on the imaging. Multiple thoracentesis performed over the course of next few months revealed exudative effusion but failed to demonstrate malignant cells. A few months later, new mediastinal and right hilar lymphadenopathy was noted on the repeat computed tomography scan. A subsequent positron-emission tomography scan revealed multiple sites of fluorodeoxyglucose (FDG)-avid mediastinal lymphadenopathy. The sites of pleural effusion were not fluorodeoxyglucose-avid. Endobronchial ultrasound and biopsy of mediastinal nodes showed adenocarcinoma with signet-ring features. Immunohistochemistry confirmed the diagnosis of metastatic colon cancer. Systemic treatment with chemotherapy was initiated. Our case highlights the importance of mediastinal evaluation by imaging during the follow-up of patients with colorectal carcinoma. The ideal management strategy for mediastinal metastasis of colorectal carcinoma remains a question, two major options being local metastasectomy or systemic chemotherapy.

An unusual complication of pigtail catheter insertion.

Thoracostomy tubes are indicated for management of air or fluid in the pleural cavity. Pigtail catheters have emerged as an effective and less morbid alternative to traditional large bore chest tubes for evacuation of pleural air or fluid. However, they do not come without complications which commonly include pneumothorax and hemothorax. Rare complications in the literature such as left ventricular penetration, subclavian artery laceration and cerebral air embolism have been reported. We report a case of a 72-year-old male who presented with dyspnea and was found to have a right-sided pleural effusion requiring thoracentesis and subsequent pigtail catheter placement because of re-accumulation of the fluid. After accidental dislodgement of the catheter, it was replaced and the following day a chest X-ray (CXR) demonstrated diffuse subcutaneous emphysema. Computed tomography (CT) scan of the chest demonstrated the pigtail catheter tracking through the right middle and lower lobes reaching the posterior pleural space. We discuss the implications of this occurrence and recommended management based on our experience.

Intercostal Artery Laceration: Rare Complication of Thoracentesis and Role of Ultrasound in Early Detection.

Hemothorax is a rare but potentially fatal postthoracentesis complication. Early clinical signs may be nonspecific resulting in diagnostic delay. A high index of suspicion is vital for early diagnosis and intervention to avoid further bleeding. Following procedure, early bedside ultrasound findings can be vital for early detection. We report a case of massive hemothorax in a 63-year-old male following therapeutic thoracentesis. Diagnosis was made following highly suggestive sonographic findings prompting thoracotomy and lacerated intercostal artery cauterization.

Left Lung Torsion: Complication of Lobar Resection for an Early Stage Lung Adenocarcinoma.

Lobar torsion is a fatal but fortunately rare occurrence following lung resection. Early clinical signs and radiographic features may be nonspecific resulting in diagnostic delay. A high index of suspicion is vital for early diagnosis and intervention to avoid further parenchymal necrosis and deadly gangrene. We report a case of left lower lobe torsion in a 76-year-old female following elective upper lobectomy for underlying lung adenocarcinoma. Diagnosis was made following highly suggestive radiographic findings prompting bronchoscopy and revision thoracotomy. An emergency detorsion failed to restore lung viability and was followed by completion pneumonectomy. The patient recovered and was discharged on the seventh postoperative day.

Primary Pulmonary Lymphoma and Synchronous Cecal Adenocarcinoma: A Rare Occurrence.

In the era of extensive imaging and increasing indications for performing PET-CT scans, the recognition of synchronous tumors may be greater than before. However, the majority of these tumors are seen to occur in the same organ system, likely because of sharing similar pathogenic mechanisms. Synchronous lung cancers of similar or differing histologies have been reported. Primary pulmonary lymphoma, which is a rare form of non-Hodgkin's lymphoma, has also been seen with a synchronous primary lung cancer. However, we report a case of a 56-year-old male diagnosed with primary pulmonary lymphoma and on PET-CT imaging, found to have a cecal lesion, the biopsy of which showed adenocarcinoma. We discuss the incidence of the co-existence of multiple tumors, the pathogenic mechanisms involved, and approaches to the management of these rare clinical scenarios.

Comparison of cytologic accuracy of endobronchial ultrasound transbronchial needle aspiration using needle suction versus no suction.

BACKGROUND AND OBJECTIVES: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a relatively new procedure initially used for lung cancer diagnosis, staging and re-staging and extended to benign diseases such as sarcoidosis and other mediastinal lesions. Previously, multiple studies evaluated the use of needle biopsy with no aspiration that did not change the diagnostic accuracy compared with needle biopsy aspiration. MATERIALS AND METHODS: All adult subjects who were scheduled to undergo EBUS-TBNA to sample mediastinal lesions were eligible. We evaluated two methods of sampling mediastinal lesions. The first method was the application of negative pressure syringe for needle suction aspiration. The second was with no suction. For every patient and every biopsy site in the same patient, we had two samples using each method. RESULTS: Among the 26 participants, 24 patients had adequate tissue using both methods (92.3%, P = 1.00). Among the 24 patients with adequate tissue using both methods, 14 patients (58.3%) had benign pathology using both methods, whereas ten patients (41.7%) had malignant pathology using both methods (P = 1.00). Among the 32 sites that were sampled, 30 sites had adequate tissue using both methods (93.8%, P = 1.00). Among the thirty sites with adequate tissue using both methods, 17 (56.7%) had benign pathology using both methods; 12 (40.0%) had malignant pathology using both methods; and one site (3.3%) had malignant pathology using suction, but benign pathology using no suction (P = 1.00). CONCLUSION: In patients undergoing EBUS-TBNA to sample mediastinal lesions, the diagnostic yield with the application of suction to needle biopsy was not statistically significant compared to no suction.

A renal angiomyolipoma with extension to the renal vein and asymptomatic fat pulmonary embolus.

Renal angiomyolipoma (AML) is a rare benign tumor that can extend into the renal vein, inferior vena cava and the right atrium. AML is a mesenchymal tumor composed of smooth muscle, fat and vascular elements. In rare instances, the tumor may release a fatty tissue to the pulmonary vasculature, which can lead to cardiopulmonary collapse and death. Only four cases of fat pulmonary embolism secondary to AML have been reported in the literature but our case was the first to present as asymptomatic. Our patient had left renal AML extending to the renal vein that was associated with fat pulmonary embolus. The patient underwent uncomplicated radical nephrectomy and was discharged home on no anticoagulation. Follow-up chest computed tomography showed no extension of the pulmonary embolism. Whether embolectomy or anticoagulation is necessary in asymptomatic pulmonary embolism secondary to renal AML is unclear. Although controversial, some surgeons prefer to place an inferior vena cava filter prior to radical nephrectomy to prevent dislodgement of new intraoperative emboli, which can lead to catastrophic outcome.

Right internal jugular venous cannulation complicated by tension hydrothorax.

Central Venous Catheter (CVC) is a common procedure performed in patients' management, especially the critically ill ones. CVC has been used as main access in patients requiring large amount of fluid resuscitation, total parenteral nutrition or measuring the central venous pressure. Although most complications associated with central venous cannulation are minimal, local and easy to control, others may be critical and rapidly fatal if not recognized and treated immediately. One of the most serious incidents that can occur post CVC placement is delayed hydrothorax. It usually results from migration and perforation of the catheter through the SVC wall. In this report, we describe a case of tension hydrothorax that occurred a few hours after placement of CVC in the right internal jugular vein. In acutely ill patients that are already unstable, making the diagnosis of tension hydrothorax secondary to CVC placement requires high level of suspicion. Prompt pleural effusion drainage like in our case is crucial for favorable outcome.

Small cell lung cancer doubling time and its effect on clinical presentation: a concise review.

Small cell lung cancer (SCLC) is one of many types rapidly growing malignant diseases, such as Burkitt's lymphoma and testicular germ cell cancers. At present, there is no reliable way to screen for SCLC, and imaging modalities tend to be delayed in detecting this type of cancer. The clinical presentation of acutely and rapidly growing SCLC can mimic those of pulmonary inflammatory or infectious disorders, and in some instances, this delays appropriate management and negatively affects patient outcome.